Healthcare Provider Details

I. General information

NPI: 1720413636
Provider Name (Legal Business Name): 616 DENTAL STUDIO PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/10/2013
Last Update Date: 09/10/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

171 MONROE AVE NW
GRAND RAPIDS MI
49503-2634
US

IV. Provider business mailing address

171 MONROE AVE NW
GRAND RAPIDS MI
49503-2634
US

V. Phone/Fax

Practice location:
  • Phone: 616-214-7865
  • Fax:
Mailing address:
  • Phone: 616-214-7865
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code122300000X
TaxonomyDentist
License Number2901020846
License Number StateMI

VIII. Authorized Official

Name: DR. MARCOS CID
Title or Position: DENTIST
Credential: D.D.S. M.S.
Phone: 616-214-7865